Dr. James Mold believes the health care profession can learn a lot from farmers.

When farmers have a problem, many times they’ll look to the network of cooperative extension agents spread across counties in a state. Mold believes creating a similar extension service network can provide that same support for health care providers.

Mold, director of the research division in the Department of Family and Preventive Medicine at the University of Oklahoma Health Sciences Center, is using a federal grant to help physicians in rural areas improve their primary care practices.

“Most of the work has to be done locally through personal relationships,” Mold said. “Practices need to work with someone they trust, someone who knows their particular situation and practice.”

Oklahoma Rep. Doug Cox, a physician who practices primarily emergency medicine during the legislative sessions, said such a network would help rural physicians, who often find it difficult to get away for continuing education because of a heavy workload.

“It’s going to implement a program that encourages physicians to work together and share resources in rural areas so they’re able to provide services that a small rural practice or a solo practitioner, or even a two-man group, could not afford to do,” Cox said.

That, he said, can help to alleviate some of the challenges facing health care in rural areas, a primary one being access because of the growing shortage of physicians.

Improving Rural Health Care

The program, Primary Care Extension in Oklahoma, funded through the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, also helps physicians see where they can make improvements, said Andy Fosmire, executive director, Rural Health Projects/Northwest Area Health Education Center in Enid, Okla. He said some primary care physicians don’t realize they have performance issues.

“They don’t have time to look around and see that they have opportunities for improvement,” he said.
One of the first steps in the research process was the development of community health improvement organizations. Those organizations employ a practice enhancement assistant who is specifically trained in identifying barriers for improvement, said Fosmire. That individual reviews how a primary physician practices medicine and then assists him or her in finding ways to improve.

“They (health care providers) have the opportunity for cross-pollination,” he said. “They have an opportunity to see what other practices are doing.”

Oklahoma was one of four states to receive the research grants called IMPaCT, for Infrastructure for Maintaining Primary Care Transformation, from HHS. The grants went to established programs looking at model state-level initiatives using primary care extension agents to improve primary care. New Mexico, North Carolina and Pennsylvania also received the grants.

The grants, Fosmire said, focus on quality of care. But addressing that quality in rural health care will require addressing other major issues affecting the broad spectrum of health care in the U.S.

Workforce Shortages

“One of the biggest things that can be done to improve the quality of rural health is, A, improve access to primary care and, B, improve the quality of primary care,” he said.

Access is a major issue across health care, but especially in rural areas. The American Association of Medical Colleges estimates the U.S. will face a shortage of more than 91,500 physicians by 2020. While the association says medical schools are increasing enrollment to address the shortage, Fosmire said it will take time to graduate the number of physicians needed.

“It’s not going to be something that’s going to be fixed tomorrow,” he said.

But access is just one challenge—albeit a big one—in providing quality care in rural areas. Brock Slabach, senior vice president for member services at the National Rural Health Association, relates access to care to the workforce shortage. But the other challenges of reimbursement, infrastructure and health disparities make providing quality care in rural areas difficult.

Many states are using a managed care model for Medicaid programs, and that could hurt reimbursement rates for rural physicians. Lower reimbursement rates could harm the recruitment of providers to rural areas, affecting access to care, Slabach said.

Infrastructure in rural communities—including buildings built in the 1940s, ’50s and ’60s, and lower rates of health information technology adoption—makes providing quality care difficult, Slabach said.
Problems related to access, reimbursement and infrastructure contribute to the disparity in health care for rural areas. “As you fix the other three, the disparities could decrease because of the attention to these other three areas,” Slabach said.

Possible Solutions

He offered several possible solutions to those health care challenges.

For infrastructure, Slabach said while state government may not be able to address these challenges specifically, it could look at some creative solutions through bond programs, particularly for public hospitals in rural areas.

States can address the reimbursement issue, he said, by protecting rural providers’ reimbursement rates when moving to managed care.

While access can be impacted by the other challenges, Slabach said fully funding and utilizing area health education centers, which are used to educate and recruit people in rural areas into medical fields, and developing loan repayment programs for physicians to practice in rural areas can go a long way.

So can allowing advanced practice nurses to fully practice, said Janet Haebler, associate director for state government affairs at the American Nurses Association. Only 17 states and the District of Columbia allow advanced practice nurses full practice authority. In the other states, nurses must work with a collaborating physician.

“All licensed health professionals are accountable for the care they deliver, so supervision and oversight is unnecessary and inappropriate,” she said. “The definition of primary care is consistent with that which (advance practice registered nurses) have the capacity to deliver.”

In fact, Haebler said, nurse practitioners came about during a previous physician shortage, and many of them served rural areas because of the absence of physicians there. She believes that could be a solution once again.

Cox of Oklahoma believes states can learn how to improve rural health care through programs like the one at the University of Oklahoma. The Affordable Care Act includes funds for states to improve the condition of their health care infrastructure. Many conservative states like Oklahoma, Cox said, won’t take advantage of those funds because they are part of the Affordable Care Act.

“Politics aside, as a physician, I hate to see us not take advantage of those federal grants to help improve the health care of our state,” he said. “I hate to see other states take advantage of it while we wither on the vine.”

Whatever solutions states consider for improving health care, Slabach has one piece of advice: “Be very aware that rural communities are different than urban in terms of the need to find solutions,” he said. “Don’t assume a one-size-fits-all program is going to be helpful for a rural community and its delivery of health care.”

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Improving Primary Health Care in Oklahoma

Huge changes are coming to health care in the United States and physicians are going to need help navigating those changes, said Dr. James Mold of Oklahoma.

Physicians will need to make changes in the way they operate practices, particularly those in rural areas, Mold said. He’s heading a pilot project funded through the Affordable Care Act that will help physicians improve their primary care practices.

The program, Primary Care Extension in Oklahoma, is one of four across the country working to develop and disseminate a health extension model. It’s similar to the agriculture extension model used across the country.

Oklahoma’s primary care extension system uses three components—the Public Health Institute of Oklahoma, a nonprofit targeting improved health through collaboration among government, academia and communities; four regional extension centers located in the state’s area health education centers, or AHECs; and 70 county health improvement organizations.

Mold said the goal is to link those entities with resources from the state and federal governments, employers and foundations, among others.

“For anybody who wants to improve health, this creates the structure where they can invest in improving the health of the population,” he said. “We need to get more resources to the areas where they’re needed.”

Building these resource networks, he said, will help to focus the efforts on improving quality of primary care.

Andy Fosmire, executive director of the Rural Health Projects/Northwest Area Health Education Center in Enid, Okla., said AHECs serve as the community link between the academic medical center at the University of Oklahoma and the practices in the communities around the state.

“Our role has been working with existing coalitions to bring their focus down to improving the community health through improving the processes within the primary care practices,” Fosmire said.

Researchers have found doctors, especially those in smaller rural communities, really don’t have time to evaluate their practices.

“They don’t realize they’re having performance issues because they do the things the way they do them and they feel like that’s successful for them,” he said. “They don’t have time to look around to see they have opportunities for improvement.”

The community health improvement organizations allow doctors in rural communities to learn from each other. A practice enhancement assistant, who is specifically trained in identifying barriers to improvement, will evaluate a medical practice and offer guidance on how to improve that practice.

For instance, the practice enhancement might focus on flu shots for senior citizens. If the goal is a 100 percent immunization rate for patients who can tolerate the shots, the practice enhancement assistant would look at practices where the rate might be lower. That assistant might look at how the physician’s office is run and offer suggestions for changes if that is the problem with raising immunization rates. If the physician needs specific training and doesn’t have time, that could be accomplished with another physician coming in, Fosmire said.

“Physicians see what they do every day—it’s kind of like a cluttered house,” he said. “You don’t see that clutter and they don’t see what’s lacking in their own practice because they’re there every day and they don’t have the opportunity to go to another physician’s office,” he said.

Part of the reason for having the community model, Mold said, is that practices need to work with someone they trust.

“Most of the work has to be done locally through personal relationships,” Mold said.

The academic medical center, he said, will provide primary improvement support for the practices.

The goal of the grants is to improve the quality of primary health care. Mold believes the health care system has a lot of catch-up to do, and the process of improving quality will be a continuous one.

“Supporting quality improvement in primary care is a bigger piece of a bigger vision,” he said. “They key features are, if you’re going to improve health, it has to be done locally.”

In addition to Oklahoma, New Mexico, North Carolina and Pennsylvania also received grants from the Agency for Healthcare Research and Quality to develop health extension models. Thirteen states participated as partners and served as sites for testing and implementing the models developed in the lead states.